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In Outbreak, Meningitis Is Reported in 5 States

An outbreak of a rare type of meningitis, linked to spinal injections for back pain, is growing and has killed four people and sickened at least 30 others in five states, health officials said on Wednesday. New cases are appearing every day.

“I’m afraid we’re going to see many more cases spread across the country,” said Dr. William Schaffner, an infectious diseases expert at Vanderbilt University in Nashville.

The patients are thought to have been infected by a steroid drug contaminated with a fungus, Aspergillus. The drug may have been shipped to 23 states, a spokesman for the Centers for Disease Control and Prevention said. This type of meningitis does not spread from person to person.

So far, cases have appeared in Tennessee, North Carolina, Florida, Virginia and Maryland. All the patients had received a treatment for back pain called a lumbar epidural steroid injection.

The drug under suspicion is methylprednisolone acetate, and health officials confirmed on Wednesday that all the infected patients had been treated with a brand of it produced by the New England Compounding Center in Framingham, Mass. So far, the incubation period seems to be from a few days to four weeks after the injection. Doctors are urging those who have had the treatment within the past few months to see a doctor if they develop symptoms like severe or worsening headaches, fever, nausea, difficulty with balance, or slurred speech.

The outbreak has raised concerns about the safety of a treatment for back pain used by millions of people a year in the United States. Sterile drugs and equipment are essential for the procedure because epidural injections involve inserting a needle into a part of the body that, for germs, can be a highway to the brain.

The outbreak has also drawn attention to the potential threats posed by compounding pharmacies like the one in New England. These pharmacies prepare drug mixtures and solutions that are not routinely available from major manufacturers, and not subject to the same rigorous safety standards that the government imposes on big drug companies.

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On Sept. 26, the New England center voluntarily recalled three lots of the drug after it was told of the problem, according to Erica Jefferson, a spokeswoman for the Food and Drug Administration. She did not know how many doses were in the lots or where they had been shipped, but the center’s Web site said New England Compounding was licensed in all 50 states. One clinic in Tennessee, where most of that state’s patients in the outbreak so far were infected, had received 2,000 vials of the drug.

On Wednesday, North Carolina’s board of pharmacy suspended the company’s permission to do business there. So far the state has had one case, and several clinics received the potentially contaminated drug, a health department spokeswoman said.

The New England center did not respond to phone messages or calls requesting an interview on Tuesday and Wednesday. By Wednesday afternoon, the phone was not being answered, and the center’s Web site, which had offered an array of steroids for pain control, was no longer available.

The lot numbers of the drug that are suspected of being contaminated are 05212012@68; 06292012@26; and 08102012@51.

Some hospitalized patients are recovering and walking the halls, but others are severely ill and in intensive care units, said Dr. Robert H. Latham, an infectious diseases specialist at St. Thomas Hospital in Nashville.

Fungal infections are notoriously stubborn and hard to treat, requiring powerful drugs that can have harsh side effects. Dr. Latham predicted that these patients would need six months to a year of treatment to get rid of the infection.

A version of this article appears in print on October 4, 2012, on Page A24 of the New York edition with the headline: In Outbreak, Meningitis Is Reported In 5 States. Order Reprints|Today's Paper|Subscribe